Part 2: Language, cascades and compounding harm

A radiologist writes: "Multilevel degenerative disc disease with disc bulges at L4-5 and L5-S1 with moderate facet arthropathy." They're describing what they see—changes present in most middle-aged spines. But without context, these words become a diagnosis that reshapes everything that follows.

Report language isn't neutral. When normal age-related changes are described using pathological terminology, the words themselves drive fear, avoidance and treatment-seeking behaviour.

This is the second in a two-part series on spinal imaging. The first article set out the evidence of harm; here we examine why scans can make things worse, highlighting the roles of language, cascades of care, and medication interactions

The power of medical language

The terminology used in imaging reports profoundly influences outcomes, as demonstrated through randomised controlled trials and experimental studies.

In a landmark randomised trial, researchers gave identical MRI findings to different groups but varied the language used to describe them. When findings were described using terms like "degenerative disc disease," patients showed significantly higher catastrophising scores, lower function, and stronger preferences for invasive treatment compared to those receiving neutral descriptions of the same anatomy (8). The spine hadn't changed. Only the words had.

Another randomised experiment with over 1,300 participants found that diagnostic labels fundamentally altered treatment expectations. When back pain was labelled as "disc bulge," "arthritis," or "degeneration," people rated their condition as more severe, expressed greater need for imaging, and showed increased preference for surgery—compared to those given non-pathologising descriptions (9). These weren't patients in pain; they were healthy volunteers responding to hypothetical scenarios. Yet the labels alone triggered cascade-seeking behaviour.

How clinicians respond to language

The effect extends to healthcare providers. A randomised study of physicians showed that when MRI reports included epidemiological context—noting how common findings are in pain-free populations—doctors were significantly less likely to attribute symptoms to those findings and less likely to recommend aggressive treatment (10). Simply adding prevalence data changed clinical decisions.

Consider the difference:

• Standard report: "Disc degeneration at L4-5 with disc bulge"
  
  
• Contextualised report: "Disc degeneration at L4-5 with disc bulge (present in 70% of asymptomatic individuals this age)"

The anatomy is identical. But the second version prevents misattribution and reduces unnecessary intervention. Yet such contextualisation remains rare in routine practice.

The nocebo effect in action

The pathway from language to disability operates through well-established psychological mechanisms. When patients believe their spine is "degenerating" or "bulging," they develop kinesiophobia—fear of movement. They adopt protective postures, reduce activity, and avoid actions they believe might cause "further damage."

Research in pain shows these beliefs become self-fulfilling. Fear and hypervigilance sensitise the nervous system, amplifying pain signals. Reduced movement leads to deconditioning. Protective postures create new sources of discomfort. What began as reassurance-seeking imaging creates the very disability it was meant to rule out.

The imaging-medication cascade

One of the most concerning patterns in compensable care is how imaging cascades interact with medication pathways to create compound harm.

The "while we wait" phenomenon

The sequence typically unfolds like this: An MRI is ordered. Results show "abnormalities." Specialist referral follows. While waiting for appointments—often weeks in workers' compensation—opioids are prescribed for "interim management." The specialist orders additional imaging or investigations. More waiting. Medication continues "until we have answers."

Large observational studies document this pattern. Workers receiving early MRI are 23% more likely to receive opioid prescriptions (4). Those getting multiple scans show even higher rates of opioid use. While these associations don't prove causation, the mechanism is clinically observable: imaging creates intervals of waiting, and waiting gets medicated.

Escalation through explanation

The imaging report doesn't just trigger medication—it justifies escalation. Once a scan shows "pathology," higher doses seem warranted. Adding medications appears logical. The "objective finding" on MRI validates subjective pain, making both doctor and patient more comfortable with pharmaceutical management.

A worker with "severe multilevel degeneration" receives different medication management than one with "mechanical back pain," even when their symptoms are identical. The scan finding—present in most people without pain—becomes the rationale for aggressive pharmacotherapy.

The surgical pathway

Perhaps most concerning is how imaging language drives surgical cascades. When patients believe they have "disc disease" or "nerve compression," conservative management feels inadequate. They seek surgical opinions. Surgeons, seeing MRI findings and a patient convinced of structural damage, are more likely to intervene.

The evidence is sobering. Workers undergoing spinal fusion have poor outcomes in compensable settings—fewer than one in five return to full duties at two years, and nearly one in five require repeat surgery (11). Yet the pathway from MRI language to operating theatre remains well-travelled, particularly when imaging reports use catastrophising terminology.

Compounding vulnerabilities

Certain factors amplify these cascade effects:

Time pressure in primary care

GPs managing compensable patients face unique pressures. Appointments must cover clinical assessment, certification, capacity evaluation, and administrative requirements. In this context, ordering imaging feels safer and quicker than explaining why it's unnecessary. The scan becomes a time-management tool, inadvertently triggering cascades.

Administrative delays

Workers' compensation approval processes add waiting periods throughout the cascade. Each delay creates an opportunity for medication escalation, activity reduction, and belief reinforcement. The administrative framework, designed to ensure appropriate care, paradoxically creates intervals where inappropriate patterns establish themselves.

Medicolegal anxiety

Clinicians report ordering "defensive imaging" more frequently in compensable cases. The perceived medicolegal risk of missing something outweighs the actual clinical risk of cascade effects. This defensive practice is understandable but creates predictable harm.

The evidence of interaction effects

Recent research reveals how imaging and medication cascades interact to worsen outcomes:

• Workers receiving both early imaging and early opioids show the longest disability durations (3)
  
  
• Multiple scans correlate with both higher opioid doses and longer opioid duration (11)
  
  
• Pre-surgical imaging intensity predicts post-surgical opioid dependence (13)

These aren't independent problems. They're interconnected cascades where each intervention makes the next more likely, creating momentum toward disability that becomes increasingly difficult to reverse.

Questions for discussion

• Could schemes advocate for contextualised reporting in radiology that includes prevalence data? What would be required to test this approach?
  
  
• Which step in the imaging-medication-surgery cascade offers the best opportunity for intervention? Primary care? Radiology reporting? Specialist triage?
  
  
• How can schemes better track cascade patterns—not just individual interventions but their sequences and interactions?

Where this meets the next challenge

Language harm and medication cascades intersect with the assessment problems documented elsewhere in this series. Workers told they have "degenerative changes" become more likely to seek multiple medical opinions and undergo repeated capacity evaluations, feeding cycles that delay rather than advance recovery.

These mechanisms sit on top of the broader evidence base, summarised in the appendix, which outlines key studies linking imaging to prolonged disability, unnecessary procedures and higher costs

Next newsletter we examine how opioid prescribing patterns in workers' compensation create their own pathways to prolonged disability and harm.

References - Part 2

Reference numbering has been continued from Part 1.

8. Rajasekaran S, Tangavel C, Aiyer SN, et al. ISSLS Prize in Clinical Science 2021: Can the reporting of degenerative disc disease be standardised? Eur Spine J. 2021;30(10):2626-2636.
   
   
9. O'Keeffe M, Ferreira GE, Harris IA, et al. Effect of diagnostic labelling on management intentions for non-specific low back pain: a randomised scenario-based experiment. Eur J Pain. 2022;26(7):1532-1545.
   
   
10. McCullough BJ, Johnson GR, Martin BI, Jarvik JG. Lumbar MR imaging and reporting epidemiology: do epidemiologic data in reports affect clinical management? Radiology. 2012;262(3):941-946.
    
    
11. Lewin AM, Fearnside M, Kuru R, Jonker BP, Naylor JM, Sheridan M, Harris IA. Rates, costs, return to work and reoperation following spinal surgery in a workers' compensation cohort in New South Wales, 2010–2018: a cohort study using administrative data. BMC Health Serv Res. 2021;21:955.
    
    
12. Deyo RA. Cascade effects of medical technology. Annu Rev Public Health. 2002;23:23-44.
    
    
13. Graves JM, Fulton-Kehoe D, Jarvik JG, Franklin GM. Health care utilization and costs associated with adherence to clinical practice guidelines for early magnetic resonance imaging among workers with acute occupational low back pain. Health Serv Res. 2014;49(2):645-665.